tan nelly 48 - DOC by dredwardmark



Name: TAN,NELLY Hospital #: 1709058 Age/Sex: 67/F Address: 1845 M Guazon St. Paco Manila Date of admission: April 12,2007 Admitting Diagnosis: Status Epilepticus Complex Partial Seizure Probably 2 to 1.Structural 2.Metabolic DM type2, PTB V Residents in charge: Dr. Drs. Magbiray, Torres, Filio, and Indon Intern-in-Chage: Maganda Clerk-in-Charge: Navarro/Ponelas/Reyes
Death Protocol This is a case of a 67 year-old female who was admitted due to seizure episodes History of Present Illness Patient had 2 previous hx of severe seizure episodes (December 2006 & February 2007). Patient had no medications for seizure episodes. Patient was apparently well until… 1 hour PTA, patient had facial muscle twitching, stiffening of upper extremities. Patient became unresponsive to verbal stimuli. There was also upward rolling of the eyeballs, drooling of saliva , hence patient sought consult and was subsequently admitted. Past Medical History She was diagnosed to have DM type 2 maintained on insulin 20 u SQ at HS, Metformin 500mg tab TID, Gliclazide 800 mg tab TID, No HPN, No BA, No Hx of Cancer. (+) PTB- treated for 1 year with poor compliance INH, Rifampicin 3 tabs OD. Family History Patient denied heredofamilial disease. Personal and Social History Nonsmoker and non-alcoholic beverage drinker Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND Gastrointestinal: (-) abdominal pain, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Heumatology: no joint pains Physical Examination: Asleep, stretcher borne Vital Signs: BP: 110/80 HR: 60 RR: 20 Temp: 37.0oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, no distended neckm veins CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, normal rate, PMI 5th ICS LMCL,regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, with full and equal pulses Assessment: Status Epilepticus

Complex Partial Seizure Probably 2 to 1.Structural 2.Metabolic DM type2, PTB V
PLAN: Patient was admitted to the service of Drs. Magbiray, Torres, Filio, and Indon. Consent for admission was secured. Patient was put on NPO while hooked on PNSS x 12 . Diagnostic procedure requested were:BUN,crea, Na, K, Ca, Mg, CPK MM, ABGs,RBS, 12 L ECG, CXR AP, CBC c PC, SGPT,SGOT, UA, FBS,HDL,LDL,TG,TV,BUA, HBA1C, EEG, Cranial Ct scan, SPUTUM AFB x3 . Medications prescribed were: Regular Insulin 5 u SQ for CBG > 250 mg/dL, Diazepam 50 mg/2 ml amp, IV PRN for frank seizures, Sucralfate 1 gram every 6 hours /NGT. O2 support via nasal canulla. On the 1st hospital day, patient is maintained on NGT. Start OF feeding at 1800 kcal /day in 3 divided doses. Still IVF to PNSS 1L + 40 meqs KCL x 6. FF up official CT scan results. Started with Ciprofloxacin 500mg 1 tab BID/NGT, K citrate 2 tabs TID/NGT. VS, NVS q1,CBG q4, o2 at 10 lpm/1m. Patient’s CBG was 300mg/dl and was given regular insulin 5 u SQ then prn >250mg/dl. Patient was intubated and

maintained on NPO., started on mannitol, hooked to mechanical ventilator support. Patient was referred back to svc consultant. Ancillary procedures delayed. PWI: Status Epilepticus 2 to Complex Partial Seizure prob metabolic in origin. Check for serum urine ketone. Endo referral was suggested. Patient was requested for serum ketone and urine ketone. On the 2nd HD, patient maintained on OF feeding @ 1800 kcal in 3 divided doses, official CT scan results showed central atrophy, SGPT,SGOT,FBS,HDL,LDL,TG,Chole,BUA were done. Results of the ff were followed up. The patient is cyanotic, tachyccardic and

hypotensive with blood pressure of less than 60 H20 palpatory. She was maintained in a Tredelenberg position. Urine output is less than 30 cc/hour. She was maintained with the following: NGT and Continued feeding with 1750 kcal.Due to persistent hypotension, Dopamine Drip was increased from 45-46 ugtt per minute to 56 minute. Intubated with ventilation to an ambu bag at 10 lpm. . Suction secretion was done every 30 minutes . Maintained in T- position with mild to moderate back rest. Vital signs monitoring and CVP measurement every 30 minute. The patient went into cardiopulmonary arrest and was resuscitated. The patient was given 1 ampule of epinephrine every 5 minutes and Noradrenaline (Levophed) drip 55 ugtt/ minute. 11 lead ECG was done. ECG result was flat. Pupils size is 4mm. fixed, nonreactive to light. However the patient was proounced dead. Post mortem care was done

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